Provider Demographics
NPI:1740778166
Name:CODY'S CENTER OF HOPE, DEDICATED PEDIATRIC CARE, PC
Entity Type:Organization
Organization Name:CODY'S CENTER OF HOPE, DEDICATED PEDIATRIC CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOLTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-350-2639
Mailing Address - Street 1:PO BOX 381442
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1442
Mailing Address - Country:US
Mailing Address - Phone:901-350-2639
Mailing Address - Fax:901-249-4563
Practice Address - Street 1:2565 HORIZON LAKE DR STE 114
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-8113
Practice Address - Country:US
Practice Address - Phone:901-350-2639
Practice Address - Fax:901-249-4563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
TN31899208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4350171Medicaid
TN3496002Medicaid